Provider Demographics
NPI:1053754630
Name:LAS VEGAS PAIN RELIEF CENTERS(RUSSO),PC
Entity type:Organization
Organization Name:LAS VEGAS PAIN RELIEF CENTERS(RUSSO),PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JON
Authorized Official - Middle Name:S
Authorized Official - Last Name:PETRICK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:702-948-2520
Mailing Address - Street 1:58 N PECOS RD
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89074-7319
Mailing Address - Country:US
Mailing Address - Phone:702-948-2520
Mailing Address - Fax:702-948-2523
Practice Address - Street 1:58 N PECOS RD
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89074-7319
Practice Address - Country:US
Practice Address - Phone:702-948-2520
Practice Address - Fax:702-948-2523
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-12
Last Update Date:2015-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVB00848111NS0005X
NV4511207RS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RS0010XAllopathic & Osteopathic PhysiciansInternal MedicineSports MedicineGroup - Multi-Specialty
No111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Multi-Specialty